Investigative Analyst (hybrid)

Investigation and Analysis 

• Support the delivery and evolution of the Claim Watch program, including identification and leading of complex and high‑risk investigations.
• Leverage reporting and AI technology to identify, research, and analyze abuse, misuse, and fraudulent claims activity with a focus on emerging patterns and systemic risk.
• Conduct complex interviews with providers and plan members and exercise independent judgment in ambiguous or precedent‑setting situations.
• Analyze utilization trends and develop provider and plan member profiling criteria to support preventative and detective fraud controls, using reporting and AI tooling.
• Identify and recommend cost‑containment and risk‑mitigation opportunities, including automation and control enhancements.
• Develop and implement preventative fraud measures and support audit, compliance, and enterprise risk activities.
• Collaborate across departments and with external stakeholders, including providers, associations, and law enforcement.
• Produce executive-level reporting and analytics that translate complex investigative findings, emerging risks, and fraud trends into actionable business insights and strategic recommendations for leadership and clients.
• Provide mentorship and guidance to investigative staff and contribute to continuous improvement of investigative practices.
• Contribute to and analyze the development of investigative reporting requirements, dashboards, and performance metrics, identifying opportunities to improve visibility into fraud, abuse, misuse, operational effectiveness, and emerging risks.
• Provide training and mentoring to peers and team members.
• Support the client/partner specific Claim Watch governance framework.